Opt-Out HIV Testing

Appraised by: Kassidy Keller SN, Katie Felch SN, Erika Meyer SN, and Tiffany Steingrueber SN

NDSU Nursing at Sanford Health, Bismarck, ND

Clinical Question:

Does using opt-out HIV screening compared to risk factor based HIV testing

increase the identification of HIV?

Articles:

Haukoos, J. S., Hopkins, E., Conroy, A. A., Silverman, M., Byyny, R. L., Eisert, S., & .Heffelfinger, J. D. (2010). Routine opt-out rapid HIV screening and detection of HIV infection in emergency department patients. JAMA: Journal of the American Medical Association, 304(3), 284-292.

Leidel, S., Wilson, S., McConigley, R., Boldy D., & Girdler, S. (2015). Health-care providers’ experiences with opt-out HIV testing: a systematic review, AIDS Care, 27(8), 1-12.doi: 10.1080/09540121.2015.1058895

Menacho, I., Sequeira, E., Muns, M., Barba, O., Leal, L., Clusa, T., & ... Leon, A. (2013).Comparison of two HIV testing strategies in primary care centres: indicator condition-guided testing vs. testing of those with non-indicator conditions. HIV Medicine, 14 (Suppl.3), 1433-37.

Prekker, M., Gary, B., Patel, R., Olives, T., Driver, B., Dunlop, S., . . . Gray, R. (2014). Acomparison of routine, opt-out HIV screening with the expected yield from physician-directed HIV testing in the ED. The American Journal of Emergency Medicine,33 (2015), 506-511.doi:10.1016/j.ajem.2014.12.057

Synthesis of Evidence:

The studies by Haukoos, Hopkins, Conroy, Silverman, Byyny, Eisert, & …Heffelfinger (2010), Leidel, Wilson, McConigley, Boldy, & Girdler (2015), Menacho, Sequeira, Muns, Barba, Leal, Clusa, & ... Leon, (2013), and Prekker, Gary, Patel, Olives, Driver, Dunlop, & . . . Gray (2014) are meaningful and valuable in their contribution to the question regarding opt-out HIV testing. Each study was appraised from Levels I to VII on their strength of their evidence. According to MelnkyFineout-Overholt (2005), Level I is a systematic review of random control trials and Level VII opinion of authorities. The article by Haukoos, et al. (2010) was Level II quasi-experimental, Leidel et al. (2015) was a Level I systematic review, Menacho et al. (2013) was a Level IV multicenter prospective cohort study, and Prekker et al. (2014) was a Level III cross-sectional study.

Haukoos et al. (2010) tested 29,925 patients and found that the identification of HIV in undiagnosed HIV patients was prevalent but not high enough to initiate a change because costs were too high. Leidel et al. (2015) investigated different HCP experiences with HIV opt-out testing and out of the 4 studies included, one study found that the HCP was in favor of implementing opt-out HIV testing because it led to an earlier diagnosis resulting in earlier treatment with good results. Menacho et al. (2013) tested two different groups, 304 patients in the non-indicator group and the 85 patients in the indicator-conditioned group. In the non-indicator group, the results concluded that 1 in 304 patients were HIV positive, and in the indicator-conditioned group, 4 in 85 patients were HIV positive. Overall, the study suggests that the indicator-condition guided HIV testing was more feasible and less expensive strategy to improve diagnosis of HIV infection than a non-targeted HIV testing strategy. Preker et al. (2014) tested 785 patients for HIV. The study concluded that 9 new HIV cases were identified with opt-out where as if physician testing was applied only 2 patients would have been identified as HIV positive. Prekker et al. (2014) suggests that it is more effective in doing routine opt-out testing.

Each study provided sufficient evidence that opt-out testing identifies more HIV-positive patients than risk factor-based testing, although results were modest and prices for each test was high. Manecho et al. (2013), who had a prospective cohort study, determined that people who had an indicated condition would only be benefited, whereas people who were not indicated were not beneficial. Leidal et al. (2015) established that of the four studies included in the systematic review, only one promoted the positive effects of opt-out HIV testing. The other three studies explained that there could be some ethical issues regarding the testing. Their thoughts were that the patients would think the HCP’s are accusing them of wrongful actions by offering the test. One other implication the study showed was that more education on the stigma and the disease of HIV would be prudent prior to standardizing opt-out HIV testing. The other two studies decided that it was feasible to do the opt-out HIV testing and it was more beneficial in the end. All three studies provided good description of how they conducted the options and also statistical measures were appropriate. It is recommended in the studies that opt-out testing is advantageous and favorable if the patient has an indicated condition.

Bottom Line:

Based on the studies Prekker et al. (2014) and Haukoos et al. (2010) reviewed routine opt-out testing is effective at identifying patients that are HIV positive who did not know they were infected and is feasible to do in a high volume ED. Almost all patients were satisfied with the testing being non-targeted and their experience of it altogether. This is a positive way to incorporate the CDC’s recommendations on HIV screening into practice and to dismiss the stigma behind HIV testing. Even though it is recommended, the HIV testing is not cost effective. The research by Menachos et al. (2013) recommended to test the indicator-conditioned patients only because it was more feasible and less expensive strategy to improve diagnosis of HIV infection. Leidel et al. (2015) recommended that more education on HIV should be given to the health care providers that are conducting the test. Therefore, all studies were inconclusive but HIV testing should still be recommended to patients being treated at the clinics and hospitals.

Implications for Nursing Practice:

Evidence suggests that there are benefits to implementing opt-out HIV testing in the emergency departments as it increases early diagnosis of HIV leading to the ability to start treatment earlier. Starting treatment earlier can lead to a better prognosis for those diagnosed. We recommend to implement opt-out HIV testing in hospitals’ Emergency Departments to increase the identification of HIV.